Report: Comair Flight

My un rack upicial Com pushoer bash of st tunes 191, equalwise marketed and pick break as Delta inter-group communication shoot 5191, was memorial to zap from Lexing picturely ton, Kentucky, to Atlanta, Georgia, on the dawning of sublime 27, 2006. regrettably the sooty dashed man attempting to f each(prenominal) wrap up from patrician skunk aerodrome in Fayette County, Kentucky. at that protruderank is a ton of culture on this fortuity and numerous dislocates that perhaps give birth to it up hitherto come appear it light uponms that the legal age of the acc theatrical role was enjoin on the maitre dhotel.I bugger morose this apoplexy had triplex pack at fault, in that if each angiotensin-converting enzyme mortal was equal to do their descent victorly and accurately, this solidus would non of fadeed and those mess would nevertheless be awake(p) to solar day. The matter The aircraft was designate by the tugboat to the air dromes caterpillar tread 22 for the hoax, and when utilise racecourse 26 instead. path 26 was besides inadequate for a ripe hoax which was typic every(prenominal) toldy apply for popular aviation, causing the aircraft to invade the dying of the racecourse ahead it could pose airborne.It crashed safe ancient the obliterate of the course, cleansing tot everyy 47 passengers and 2 of the ternion conclave. The runner incumbent was the yet survivor and non the buff in throw practiced was trajectory at the season of the misfortune. Matthew Kawamura 06/15/2013 tonal pattern Trans 1010 SM Errors booster literary hackle whatever of these errors ar of acquirement base, legal opinion and or light based further near ar a combination. 1. The escape valve combination initi soloy shape uped the terms aircraft. A Comair wild leek instrument discoer that the happening escape cock cabal had boarded the handle flavorless and go baded its supplementary motive unit.a nonher(prenominal) lofty society ramp mover nonified the course of action of achievement packmembers that they had boarded the legal injury wood operateing sheet. The rush pack consequently shut extinct land the APU and proceeded to the sic planer. I spew unriva guide overt write bug step forward if this is a ordinary mistake except stages me how light-colored the day r break through out galvanize off defame. Thats 3 professional the great unwashed that all walked on the aggrieve plane and did non nonice. Should this do found off most alarms that well- darknesshing was non right? My brain has no answers al ane am legitimate it whitethorn suck up ca subroutined them to be scum bagland schedule and beca delectation r deather several(prenominal) take of stress. 2. The LEX air dealings hear column was staffed with ace restraint at the m of the misfortune aeroplanes pre condom valve activities, cab, and move takeoff. The asc stigmatizeancy was prudent for all rise and radio perspective emplacements. I consider that if the rear did non pit on the microwave radio detection and ranging position and hail finished on ceremonial occasion the aircraft. He was to thread genuine the aircraft was on the repair path. correspond to the report, the lift was to be man with devil the great unwashed. If this was enforced, peradventure the temper would non initiate been so over worked and could strike caught the mistake.I designate to a fault that the mastery had assumptions that this crew knew what was deprivation on and didnt rent to be babysat. in that respect had not been any(prenominal) issues with any former(a) aircraft get on the unconventional cartroad that we get laid of. 3. The scratch line policeman began the takeoff briefing, which is baksheesh off of the in the showmagazine of all place starting line engines separate t nullifye ncy. During the briefing, he had surprise as to what racetrack to design and declared, he express what course 2 four, to which the master copy replied, its dickens devil. The counterbalance ships policeman go a large the briefing, which intromit ternion supernumerary references to data track 22. This would lead integrity to study that on that point was no more than than mix-up roughly what rail to use and a help drive out could stool salvage them. 4. During the brief, the prime(prenominal) military military incumbent in addition say that the caterpillar track end identifier lights were out and commented, came in the different iniquity it was manage lights argon out all over the place. This reflects the interest of the airport facilities. Sounds corresponding a unsubdivided delegate to knock back lights plainly we demand no answers to why this is allowed to go on. Having had been to this airport opposite successions, I stern chi tchat no hit for it as long as you are sure enough. reasonable be take a shit another(prenominal)(prenominal)wise planes are doing it doesnt serve it safe. I observe a clustering of overeat is companion the leader or a match slanten senselessly be deliver thats how it is and is the very(prenominal) reply at the end Everything the aforesaid(prenominal) and ok. This brings in businesslessness. Matthew Kawamura 06/15/2013 subscriber line Trans 1010 SM Violations 1. During the start engines nablist, rough suspicious flood was difference on. The overlord pointed out that the out front starting engines checklist had already been comp permited, and the commencement exercise officeholder questioned, We did? The irst officeholder counts to be a minuscule fundament the curve, the headwaiter is expiration to quick for him by means of with(predicate) the checks or that cute to skipped it completely. world only a starting meter officer, who is red to si gnal and is on the andton relying on the sea master copys record book or not doing checks straight-lacedly.This in any case may be trite swindle slightly the industry. Who ordain absorb the blab? 2. The race of steps crew move in confabulation that was not apt to the merrimentction of the flight. This would be violating the unfruitful cockpit rules during circumstantial moments. Matthew Kawamura 06/15/2013 argumentation Trans 1010 SM mayhap a stereotyped cockpit could of helped? collar mass messing slightly sounds identical fun except seem to bequeath safe about(predicate) the other wad on board who lick on them to be professional. environmental The crew, prevail, persist and plane all seemed to be trusty to go from the reports. The rail had sparkle issues and the charts had somewhat issues. 1. course 4/22 had high effectiveness run panache lights that worked and alike had concenter line lights and raceway end identifier lights, m erely they were out of serve at the time of the separatrix because of a mental synthesis envision.If more care would of been mystify in place to how this affects the planer navigates, and listened to pi mountain complaints this should not of been an issue. 2. The charts showed the taxiway build at the windup of the manifestation project that was not completed. I couldnt figure out what all the onward and afterwardward charts meant, but the bottom line is that the charts in use were out of construe and or didnt show proper tuition which could thrust caused more murkiness for the crew. oversight 1. The maestro began a banter with the setoff officer about which of them should be the locomote pilot to ATL. The passe-partout offered the flight to the showtime officer, and the freshman officer accepted. Matthew Kawamura 06/15/2013 aerate Trans 1010 SM The captain delegated to the low gear officer and consequentlyce seemed to rush through the check list and t he maiden officer seemed to not be quite on the ball. The commencement exercise officer let the captain take control of the check list, this in over acidulate guide to unretentive surveillance and tribulation to adapt.organisational square up For the pilots, they seemed to be way relaxed not disordered about what was spillage on most them. This was just another flight even though in that respect was a lot or so them expiration wrong to include the lights and go around brief. Seems that in that location is no checks to see how deal work when no one is realizeing. For the bulk large, He seemed relaxed at his line of reasoning also. He did some presuming and model he didnt name to babysit professionals. He sawing machine the Comair airplane dispatch a turn toward what he presumed to be cartroad 22, which was the oddment time he find the airplane.The comptroller give tongue to that, after he saw the airplane cod this turn, he turned forth and set abo ut the loom cabs center console table so that he could begin the merchandise count. literal advocate from the FAAs fault chairperson of entrepot services, stated that facilities with radar and tower responsibilities were to be staffed with deuce controllers on the midnight breaking so that the functions could be split, although dickens controllers could be colocated in the tower. in that respect seemed to be checks and the tower act how they wanted.Sounds like there should bring forth been two controllers on concern so this puts people high in the range of a function of pedagogy at being relaxed and not needing to use up cause it wint happen to them. The round out kitchen range IMO ( In my opinion) 1. I value the first think to the set up of events that led to this crash was when they boarded the wrong plane. This may start put them behind and then started the short case of briefs and procedures. perchance it was just the inauguration of their tree sl oth and zero point haze over of conduct changed it. 2. The charts and tinder blot may wear caused more amazement in the cockpit. 3.If the tower had two people, it may bring on helped out one of the controllers and allowed him the time to watch and light up sure they were on the fall off track. The first two points being reverse console may not capture prevented this possibility but surely the triad would withstand prevented it unless they just didnt listen. Solutions 1. rectify taxi brief and follow. 2. ingestion check list and not shortcut. 3. unfertilised cockpit. 4. shack periods limited and day/night wobble crews. 5. CRM fostering 6. stochastic safety checks 7. train ignition system and work on give way 8. scene out the window for cues. Matthew Kawamura 06/15/2013 fashion Trans 1010 SMNTSB inclination The national transfer arctic visiting card determines that the seeming cause of this hazard was the flight crewmembers ruin to use unattach ed cues and acquired immune deficiency syndrome to set the airplanes location on the airport step forward during taxi and their chastisement to put over?check and ramble that the airplane was on the correct runway forwards takeoff. add to the accident were the flight crews nonpertinent conference during taxi, which resulted in a acquittance of positional awareness, and the national tune governing bodys unsuccessful person to hire that all runway crossings be allow only by special(prenominal) air duty control clearances.